Rohan M. Modi

Novel techniques for diagnosis of serous cystadenoma: fern pattern of vascularity confirmed by in vivo and ex vivo confocal laser endomicroscopy

Novel Techniques for Diagnosis of Serous Cystadenoma: Fern Pattern of Vascularity Confi rmed by Inand ex-vivo Confocal Laser Endomicroscopy Rohan M. Modi, MD1, Amrit K. Kamboj, MD2, Benjamin J. Swanson, MD, PhD1, Peter Muscarella, II, MD1, Darwin L. Conwell, MD, MS1, Somashekar G. Krishna, MD, MPH1. 1. Th e Ohio State University Wexner Medical Center, Columbus, OH; 2. Th e Ohio State University College of Medicine, Columbus, OH.

In vivo and ex vivo confocal endomicroscopy of pancreatic cystic lesions: A prospective study

AIM To investigate the reproducibility of the in vivo endoscopic ultrasound (EUS) - guided needle based confocal endomicroscopy (nCLE) image patterns in an ex vivo setting and compare these to surgical histopathology for characterizing pancreatic cystic lesions (PCLs). METHODS In a prospective study evaluating EUS-nCLE for evaluation of PCLs, 10 subjects underwent an in vivo nCLE (AQ-Flex nCLE miniprobe; Cellvizio, MaunaKea, Paris, France) during EUS and ex vivo probe based CLE (pCLE) of the PCL (Gastroflex ultrahigh definition probe, Cellvizio) after surgical resection. Biopsies were obtained from ex vivo CLE-imaged areas for comparative histopathology. All subjects received intravenous fluorescein prior to EUS and pancreatic surgery for in vivo and ex vivo CLE imaging respectively. RESULTS A total of 10 subjects (mean age 53 ± 12 years; 5 female) with a mean PCL size of 34.8 ± 14.3 mm were enrolled. Surgical histopathology confirmed 2 intraductal papillary mucinous neoplasms (IPMNs), 3 mucinous cystic neoplasms (MCNs), 2 cystic neuroendocrine tumors (cystic-NETs), 1 serous cystadenoma (SCA), and 2 squamous lined PCLs. Characteristic in vivo nCLE image patterns included papillary projections for IPMNs, horizon-type epithelial bands for MCNs, nests and trabeculae of cells for cystic-NETs, and a “fern pattern” of vascularity for SCA. Identical image patterns were observed during ex vivo pCLE imaging of the surgically resected PCLs. Both in vivo and ex vivo CLE imaging findings correlated with surgical histopathology. CONCLUSION In vivo nCLE patterns are reproducible in ex vivo pCLE for all major neoplastic PCLs. These findings add further support the application of EUS-nCLE as an imaging biomarker in the diagnosis of PCLs.

Novel technique for diagnosis of mucinous cystic neoplasms: in vivo and ex vivo confocal laser endomicroscopy

A 51-year-old woman presented with abdominal pain, and a CT scan of the abdomen revealed a cystic lesion in the tail of the pancreas measuring 4.4 cm 3.8 cm. An EUS demonstrated a 4.1 cm 4.0 cm anechoic cystic lesion without main pancreatic duct involvement. The differential diagnosis was broad and included intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and serous cystadenoma (SCA). However, MCN was slightly higher on the differential diagnosis because these lesions are typically seen in middle-aged women, with the majority of lesions seen in the pancreatic body or tail without communication with the main pancreatic duct. Here we present a relatively new technique, needlebased confocal laser endomicroscopy (nCLE), which allows for real-time image acquisition during EUS. The nCLE demonstrated solitary epithelial bands without any papillary conformation (Video 1, available online at www.VideoGIE.org) (Fig. 1). These bands are best described as having a horizon-type configuration with variable thickness, suggestive of a diagnosis of MCN.

A dual-modality approach of endobiliary radiofrequency ablation and self-expandable metal stent placement to control malignant hemobilia

A 69-year-old man with a history of metastatic pancreatic cancer involving the head of the pancreas and previous placement of an uncovered self-expandable metal stent (SEMS) for malignant biliary obstruction presented to the hospital with new-onset jaundice, melena, and a drop in hemoglobin from 11.0 to 5.6 g/dL over 2 weeks. Given his clinical picture, an urgent upper endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) were performed (▶Video1). ERCP demonstrated brisk hemobilia with cholangiogram evidence of stent obstruction, which was most likely secondary to tumor ingrowth (▶Fig. 1 a, ▶Video1). Balloon sweeps of the bile duct confirmed suspicion of bleeding from the diffuse tumor ingrowth. Endobiliary radiofrequency ablation (RFA) was performed for tumor destruction and hemostasis (▶Fig. 1b, ▶Video1). This was chosen as the initial treatment approach because, given the degree of blood loss, it was important to confirm control of bleeding prior to placement of a covered SEMS. The entire length of the stent was fulgurated with the RFA probe at 10 watts for 90 seconds in sequential fashion. As a result, there was prompt cessation of hemobilia (▶Fig. 1 c, ▶Video1). A fully covered SEMS was placed within the uncovered metal stent to prevent continued tumor ingrowth. The patient had no further evidence of bleeding following the intervention, and hemoglobin levels stabilized. Endoscopic interventions are limited for hemobilia and have historically relied on the tamponade physiology of fully covered SEMS [1–3]. This case presents a E-Videos

Outcomes of liver transplantation in patients with hepatorenal syndrome.

Hepatorenal syndrome (HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation (LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40%, respectively. In this article, we reviewed current concepts in HRS pathophysiology, guidelines for HRS diagnosis, effective treatment options presently available, and controversies surrounding liver alone vs simultaneous liver kidney transplant (SLKT) in transplant candidates. Many treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT have remained a mainstay in the treatment of HRS. Unfortunately, even after aggressive measures such as terlipressin use, the rate of recovery is less than 50% of patients. Moreover, current SLKT guidelines include: (1) estimation of glomerular filtration rate of 30 mL/min or less for 4-8 wk; (2) proteinuria > 2 g/d; or (3) biopsy proven interstitial fibrosis or glomerulosclerosis. Even with these updated criteria there is a lack of consistency regarding long-term benefits for SLKT vs LT alone. Finally, in regards to kidney dysfunction in the post-transplant setting, an estimation of glomerular filtration rate < 60 mL/min per 1.73 m(2) may be associated with an increased risk of patients having long-term end stage renal disease. HRS is common in patients with cirrhosis and those on liver transplant waitlist. Prompt identification and therapy initiation in transplant candidates with HRS may improve post-transplantation outcomes. Future studies identifying optimal vasoconstrictor regimens, alternative therapies, and factors predictive of response to therapy are needed. The appropriate use of SLKT in patients with HRS remains controversial and requires further evidence by the transplant community.

A comprehensive examination of the novel techniques used for in vivo and ex vivo confocal laser endomicroscopy of pancreatic cystic lesions

re 1. A, In vivo needle-based confocal laser endomicroscopic view of an intraductal papillary mucinous neoplasm. B, Ex vivo confocal laser endooscopic view of an intraductal papillary mucinous neoplasm. Both demonstrate fingerlike projections, or papillae. C, Histopathologic view of an intral papillary mucinous neoplasm showing tall columnar epithelium with elongated nuclei and goblet cells (H&E, orig. mag. 40).

Impact of transjugular intrahepatic porto-systemic shunt on post liver transplantation outcomes: Study based on the United Network for Organ Sharing database

AIM To determine the impact of transjugular intrahepatic porto-systemic shunt (TIPS) on post liver transplantation (LT) outcomes. METHODS Utilizing the United Network for Organ Sharing (UNOS) database, we compared patients who underwent LT from 2002 to 2013 who had underwent TIPS to those without TIPS for the management of ascites while on the LT waitlist. The impact of TIPS on 30-d mortality, length of stay (LOS), and need for re-LT were studied. For evaluation of mean differences between baseline characteristics for patients with and without TIPS, we used unpaired t-tests for continuous measures and χ2 tests for categorical measures. We estimated the impact of TIPS on each of the outcome measures. Multivariate analyses were conducted on the study population to explore the effect of TIPS on 30-d mortality post-LT, need for re-LT and LOS. All covariates were included in logistic regression analysis. RESULTS We included adult patients (age ≥ 18 years) who underwent LT from May 2002 to September 2013. Only those undergoing TIPS after listing and before liver transplant were included in the TIPS group. We excluded patients with variceal bleeding within two weeks of listing for LT and those listed for acute liver failure or hepatocellular carcinoma. Of 114770 LT in the UNOS database, 32783 (28.5%) met inclusion criteria. Of these 1366 (4.2%) had TIPS between the time of listing and LT. We found that TIPS increased the days on waitlist (408 ± 553 d) as compared to those without TIPS (183 ± 330 d), P < 0.001. Multivariate analysis showed that TIPS had no effect on 30-d post LT mortality (OR = 1.26; 95%CI: 0.91-1.76) and re-LT (OR = 0.61; 95%CI: 0.36-1.05). Pre-transplant hepatic encephalopathy added 3.46 d (95%CI: 2.37-4.55, P < 0.001), followed by 2.16 d (95%CI: 0.92-3.38, P = 0.001) by TIPS to LOS. CONCLUSION TIPS did increase time on waitlist for LT. More importantly, TIPS was not associated with 30-d mortality and re-LT, but it did lengthen hospital LOS after transplantation.

Effect of transplant center volume on post-transplant survival in patients listed for simultaneous liver and kidney transplantation

AIM To examine the effect of center size on survival differences between simultaneous liver kidney transplantation (SLKT) and liver transplantation alone (LTA) in SLKT-listed patients. METHODS The United Network of Organ Sharing database was queried for patients ≥ 18 years of age listed for SLKT between February 2002 and December 2015. Post-transplant survival was evaluated using stratified Cox regression with interaction between transplant type (LTA vs SLKT) and center volume. RESULTS During the study period, 393 of 4580 patients (9%) listed for SLKT underwent a LTA. Overall mortality was higher among LTA recipients (180/393, 46%) than SLKT recipients (1107/4187, 26%). The Cox model predicted a significant survival disadvantage for patients receiving LTA vs SLKT [hazard ratio, hazard ratio (HR) = 2.85; 95%CI: 2.21, 3.66; P < 0.001] in centers performing 30 SLKT over the study period. This disadvantage was modestly attenuated as center SLKT volume increased, with a 3% reduction (HR = 0.97; 95%CI: 0.95, 0.99; P = 0.010) for every 10 SLKs performed. CONCLUSION In conclusion, LTA is associated with increased mortality among patients listed for SLKT. This difference is modestly attenuated at more experienced centers and may explain inconsistencies between smaller-center and larger registry-wide studies comparing SLKT and LTA outcomes.

Paracentesis in cirrhotics is associated with increased risk of 30-day readmission

AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites. METHODS A retrospective analysis of the nationwide readmission database (NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission. RESULTS Of the 59597 patients included in this study, 18319 (31%) were readmitted within 30 d. Majority (58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832 (50%) patients on index admission. Independent predictors of 30-d readmission included age < 40 (OR: 1.39; CI: 1.19-1.64), age 40-64 (OR: 1.19; CI: 1.09-1.30), Medicaid (OR: 1.21; CI: 1.04-1.41) and Medicare coverage (OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity (OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis (OR: 1.16; CI: 1.10-1.23), paracentesis on index admission (OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma (OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted (P-value: 0.34); however cost of care was significantly more on 30 d readmission (

Pancreatic mucinous cystic neoplasm masquerading as pseudocyst

30959 ± 762) as compared to index admission (